Rethinking International Medicine: Moving beyond Medical Tourism

Introduction

Now more than ever we are a globalized world, so problems that afflict one part of the globe affect all parts of the globe. Due to growing global health threats including climate change, refugee and migrant displacements and the easy spread of infectious pathology such as that we have seen with the COVID19 pandemic, international medicine is no longer a luxury, but a necessity in today’s globalized world. However, over the past several decades, there has been a decrease in the excitement surrounding global health. Isolationism and nationalistic ideologies have taken root amongst many high-income countries, funding for global initiatives has been cut and the pervasive nature of social media has perpetuated a fear about partaking in exploitative medical tourism. All of this has further clouded the positive impacts that studying and implementing international medicine curricula and projects can have on a larger scale. Those in the field of emergency medicine are uniquely qualified to engage in international medicine as these skills can be easily transferred to many different environments and more so in austere conditions with limited resources. It is thus important that medical education programs, especially those in emergency medicine, address ethical concerns and teach a framework that encourages international engagement beyond medical tourism.

Definitions

–International Medicine: (global health) a field within healthcare that has a public health emphasis across regional or national boundaries.

–Medical Tourism: the term commonly used to describe international travel for the purpose of providing or receiving medical care. This can be synonymous with “short term medical missions”.

–High-Income Countries (HIC): countries as of 2022, with >$13,846 gross national income (GNI).^9,10

–Low-Middle Income Countries (LMIC): Low-income countries have <$1,135 GNI per capita and middle-income countries have between $1,135 and $13,845 GNI per capita.^9,10

History

In order to understand the complexity and the nuances of how global health has been intertwined with religion, imperialism and even racism, it is imperative to understand a brief history of medical tourism’s modern development. Some of the earliest documentation of medical tourism began in the 19th century when American Peter Parker was sent to China in 1834 as the first Protestant medical missionary.^2,5,8 He was a skilled surgeon and ophthalmologist and his success in treating previously untreatable conditions won over the initial hesitations of the local population. It became apparent that through Western medicine, missionaries could gain access to parts of society that were otherwise closed off to the rest of the world.

Thus began a complex relationship between providing medical care and incorporating religious conversions.

More American doctors followed Parker and in 1838 they founded the world’s first society for medical missions: the Medical Missionary Society of China. Parker later traveled to Edinburgh, Scotland in 1841 and appealed to a number of the city’s leading doctors to establish the Edinburgh Medical Missionary Society which was the first of its kind in Europe.^5,8 During this time period, many developing nations’ healthcare began to be delivered by Catholic and protestant missionaries, as foreigners earned their right to preach through providing healthcare to local communities. This in part explains why many international medical efforts are still affiliated with faith-based organizations and often contain elements of missionary work integrated into their clinical projects.

Over time, there was a shift from religious affiliations towards a more secular form of medical tourism. The International Committee for the Red Cross and Red Crescent was founded in 1863 becoming one of the first organizations operating outside of government or church influence. This set the stage for humanitarian aid expansion globally and over the next century, medical missions experienced an unprecedented time of infrastructure building. However, many of these developed institutions were formed out of necessity, as this was also the time period of both World Wars, where imperialism and war had spread across the globe and ravaged countries like never before. It is this history of imperialist expansion, by mostly European countries, that contributes to the reluctance of some receiving LMICs to this day. It is imperative to understand this context as many ethical concerns still arise about the implication of majority Caucasian countries sending medical workers to ethnically diverse communities to practice international medicine.

As the 20^th century came to a close, there were geopolitical changes that saw the influence of international organizations diminish. The spread of socialist and nationalist movements throughout various regions, the decolonization of many African countries and a shift in academic perspectives saw much of the financial backing by donors dry up and the medical missions infrastructure began to collapse.1 Mission-sending organizations could no longer support running hospitals, supplying staff, or maintaining a supply of expensive equipment and drugs. Hospitals were closed, sold, or nationalized frequently during this era.

Then came a 21st century re-birth. Organizations such as The Gates Foundation began to fund international efforts and influence outcomes on a global scale. By 2010, the World Health Organization began to set global standards for various aspects of healthcare bringing the global community one step closer to a level playing field.

Ethical Concerns

Ethical considerations regarding international medicine have become a key concern amongst academics, clinicians and students during this rebirth of global health. Some of the more pressing problems that exist with short term medical missions (STMMs) include the perpetuation of colonization, exploitative practices and the misuse of resources.

The field of medicine has a long and troubled history in formerly colonized countries and thus concerns about STMMs perpetuating imperialist beliefs underscore much of their work. Historically, efforts to “modernize” or “civilize” indigenous communities by missionaries or colonizers often meant debunking superstitious and mythological understandings of health and healing. This practice has transcended to current times as even today, there is the pervasive belief that the West offers modernized solutions to LMICs problems. This then undermines efforts and ideas arising from the local communities and perpetuates the stereotype that Western practices equate to best practices. Therefore, by participating in international medicine there is a concern of perpetuating this Western influence abroad without considering LMICs autonomy to drive their own progress.

Another critique of short-term medical missions is that the sending HIC institutions ironically reap more of the benefits than their LMIC counterparts through educationally or socially exploitative practices. There is the belief that the West continues to utilize LMICs as a resource from which to draw knowledge and experience from without truly offering sustainable benefits to the host. This can be witnessed in the research realm, as there are publication co-authorship inequities that often benefit those from HICs. It can also be seen clinically when practitioners or trainees travel abroad to practice surgical techniques or clinical medicine on a local population, as oftentimes the level of training and supervision required to perform these skills in their home HIC is vastly different. Exploitation may also come in the form of social media usage, as it has the potential to exploit local cultures and communities to garner attention without providing anything substantive in return. Even the most well-meaning trips can come across as problematic given the inherent inequities in terms of overall decision-making, which is often related to one-sided funding coming from the HICs.

A third and more practical concern is the deployment of vital resources needed to “host” foreign medical personnel. Already working with limited resources and employees, local staff will often need to take time to translate, explain and mentor international visitors. This results in them diverting their own energy and focus from providing care to patients or supporting their own students who will continue to work in the environment long after the international provider has gone. There is also the emotional burden placed on host institutions to create a comfortable experience for their visitors. Many visiting students are often confronted by unfamiliar degrees of suffering and resource disparities while needing substantial clinical supervision, all serving to potentially burden hosts further.

Benefits

The above ethical concerns should be given serious consideration, but are not grounds to abandon the concept of international medicine efforts altogether. If done thoughtfully, there is an opportunity for benefit to all parties involved. The enhancement of clinical skills, the exchange of ideas, the pursuit of broad research, all while gaining new perspectives and exploring different cultures throughout the world are some of the many benefits that international medicine can provide.

The field of international emergency medicine has expanded from disaster relief efforts to opportunities for research and resident education with the potential for substantial lasting impacts. A 2016 study titled “Global health programs and partnerships: evidence of mutual benefit and equity”⁷, assessed perceived benefits by using survey information from 82 North American academic institutions and 46 international partnering institutions. Overall, there was near unanimous agreement that global health partnerships were mutually beneficial, with the greatest impacts being in research and education collaboration. Other published reviews^3,7,11 indicate that international medical electives may lead to a number of lasting benefits, such as the desire to continue with similar experiences, greater awareness of the needs of LMICs, improved clinical skills, better resource utilization and positive influences on career pathways. A UK study went on to suggest that students who had to adjust to living in a foreign culture, developed better empathy and respect for immigrants in similar positions back in their home HICs.¹³ Taken altogether, the studies being published continually show that the benefits to international medicine are bountiful and far-reaching.

Moving Beyond Medical Tourism

There are plenty of barriers facing physicians who consider getting involved in the global health sector. However, it is important to start somewhere and through a basic framework, physicians can navigate how to best move forward in this field. Based on the ideas of global advocates and their published works, there are three recurring factors that promote success and combat the aforementioned ethical concerns. 1. Bidirectional collaboration, 2. sustainable investment and 3. adaptability are all factors that may improve the overall value of international medicine partnerships for both stakeholders.

Bidirectional collaboration involves both the sending institution and the receiving one emphasizing their priorities and addressing ethical concerns that may arise. There is a repeated finding among surveys that volunteers from high-income countries often prioritize providing clinical care during the STMM, but local hosts ideally want volunteers to assist with capacity building.^3,7,11 Communication is key to ensuring that both parties benefit from the collaboration and that there is no discordance in regards to expectations and goals. In addition to communication, another example of where LMIC partners could benefit much more is with bidirectional education exchanges. This entails funding and creating an infrastructure where HICs host LMIC students or physicians. This ideal exchange ensures that the flow of ideas is bidirectional, not unilaterally flowing from HICs to LMICs as is a common practice now. Along with this educational collaboration, the lack of LMIC input into research projects and published papers needs to be addressed. Inclusion of LMIC collaborators at international conferences and invitation to engage in novel research will help promote better partnerships moving forward.

The second key to success in global health is ensuring sustainability. The goal should be to make a lasting impact beyond one’s physical presence in a country or location. A common critique of medical missions is that often things tend to work while the sending partners are present but then fail once they leave. Sustainable projects thus require local buy-in, in addition to an enduring stream of human, material and fiscal resources. One way to ensure a sustainable partnership is to “adopt” a hospital or a community, which promotes continuity and capacity building long-term.^3,7,11 Sustainable projects also more often than not include those in education and research, as opposed to the old adage of donations or clinical work. By allowing LMICs to drive their needs assessment and having HICs participate more in capacity building, sustainable partnerships can be built to last generations.

The third component is adaptability. Anyone who partakes in international medicine must adjust to practical limitations while seeking personal growth and improvement. One popular idea in the global health community is that of pre-travel orientations to receive site-specific preparation from experienced individuals prior to departure. Pre-departure training programs should cover clear educational objectives, health and safety concerns, and any potential ethical issues. It is also helpful to take a short course in local language and culture. International medicine programs should cultivate flexibility, particularly in the HICs recognizing that despite their training, they will not be local experts and will need to adapt their research, projects, or clinical efforts based on available resources. Feedback and debriefing are also key components that ensure both partners are achieving their goals and objectives. Ongoing feedback from both the HIC and LMIC leaders provides opportunities for meaningful improvement in the partnership so that it may continue to adapt and grow.

In the end, there is no wrong way to help others, but we can all do better. With an understanding of history, consideration of ethical concerns and a thoughtful framework through which to engage in global health initiatives, emergency physicians can exert lasting positive impacts beyond geopolitical borders. Through this framework, the field of international medicine can continue to grow and move beyond medical tourism.

Resources

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• Stevens, George Barker. and W Fisher Markwick. The Life, Letters and Journals of the Rev. and Hon. Peter Parker, M.D. Missionary, Physician, and Diplomatist: The Father of Medical Missions and Founder of the Ophthalmic Hospital in Canton. Boston: Congregational Sunday-School and Pub. Society, 1896.
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